SOAP Noting System
Upcoming SlideShare
Loading in...5
×
 

SOAP Noting System

on

  • 942 views

 

Statistics

Views

Total Views
942
Views on SlideShare
942
Embed Views
0

Actions

Likes
0
Downloads
19
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    SOAP Noting System SOAP Noting System Presentation Transcript

    • Omar Hamad AlKadhi, RCsDP SOAPOmar Hamad AlKadhi 1
    • S O A P Omar Hamad AlKadhi, RCsDPContents Subjective Objective • Contents: • Slide 3-4: Introduction • Slide #8: AssessmentPlan • Slide#5: History • Slide #9: Plan • Slide #6: Subjective • Slide #10-11: Example • Slide #7: Objective Assessment 2
    • S O A P Omar Hamad AlKadhi, RCsDPContents SOAP • Importance of complete and efficient noting. • The SOAP system is designed to organize and simplify noting in hospital and office settings for all healthcare professionals. 3
    • S O A P Omar Hamad AlKadhi, RCsDPContents Subjective Objective • Its a square!Plan • Put all the information inside. Assessment 4
    • S O A P Omar Hamad AlKadhi, RCsDPContents SOAP • Start with a brief history. • (Patient’s age, Nationality, Gender , Occupation, Past medical history, Habits, and Past dental history). 5
    • S Omar Hamad AlKadhi, RCsDPContents Subjective • Subjective, Symptoms, Chief Complaint, History of present illness. 6
    • O Omar Hamad AlKadhi, RCsDPContents Objective • What clinical and radiographic examinations reveal. 7
    • A Omar Hamad AlKadhi, RCsDPContents • Assessment, Problem list, Diagnosis. The list is better be numbered and corresponding numbers in the “Plan” section are made. Assessment 8
    • P Omar Hamad AlKadhi, RCsDPContentsPlan • Plan of the treatment, What is going to be done today, and in the Next Visit. 9
    • S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Example• Pt Patient • YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies • Hx:• Cig. Cigarettes• EOE Extra-Oral Examination • Pt is 22 yo Saudi , Student. Med Hx is• IOE Intra-Oral Examination• Tx Treatment not significant. NKDA. Not using any• ē With drugs. Smoker 1/2 pack a day of cig.• Tab. Tablet• PRN As needed Dental Hx includes several restoration,• Q6H Every 6 hours• Male RCT and extraction.• Female • S: • CC: "I have severe pain in my upper left last tooth (T#26), the pain is spontaneous and it started 2 days ago, it is betterSubjective when I take Panadol, and I want to fix all my teeth".ObjectiveAssessmentPlan 10
    • S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Example• Pt Patient • YO Years Old• Med. Medical• Hx History • O:• NKDA No Known Drug Allergies • EOE:• Cig. Cigarettes• EOE Extra-Oral Examination • Lymph nodes, TMJ, Skin, Lips, and Face• IOE Intra-Oral Examination all WNL.• Tx Treatment• ē With • IOE:• Tab. Tablet• PRN As needed • T#26 Thermal test revealed lingering• Q6H Every 6 hours pain response (CO2).• Male • T#26 is tender to palpation and• Female percussion. • Moderate plaque accumulation, Generalized gingival inflammation, BOP, Loss of stippling, Slight redness, and Edema (see chart).Subjective • RR of t# 46. Missing t#24. • Slight drifting of t#23, 25 into space ofObjective missing t#24. • Radiographically:Assessment •T#26, widening of the PDL space, and a well defined, corticated radiolucent lesion.Plan 11
    • S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Example• Pt Patient • YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies• Cig. Cigarettes• EOE Extra-Oral Examination• IOE Intra-Oral Examination• Tx Treatment• ē With• Tab. Tablet• PRN As needed • A:• Q6H Every 6 hours 1. T#26, Caries, Irreversible pulpitis, and• Male Acute Apical Abscess.• Female 2. Generalized Moderate Plaque-induced gingival disease. 3. RR of t#46. 4. Caries in t#16, 26, 34. 5. Missing t#24.SubjectiveObjectiveAssessmentPlan 12
    • S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Example• Pt Patient • YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies• Cig. Cigarettes• EOE Extra-Oral Examination• IOE Intra-Oral Examination• Tx Treatment• ē With• Tab. Tablet• PRN As needed• Q6H Every 6 hours • P:• Male 1. RCT and cusp coverage.• Female 2. Scaling and polishing. 3. Extraction of the RR of t#46. 4. Removal of caries and restoration of t#16, 34. 5. Implant or FPD in the space of missingSubjective t#24.ObjectiveAssessmentPlan 13
    • S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Procedure• Pt Patient • YO Years Old • Today:• Med. Medical• Hx History • Explained the tx to the patient.• NKDA No Known Drug Allergies • Infiltration anesthesia was administered, 2 carpules 2% lidocaine ē 1:100k adrenaline in the• Cig. Cigarettes• EOE Extra-Oral Examination area of t#26.• IOE Intra-Oral Examination • R.D. Was applied, single isolation.• Tx Treatment• ē With • Caries was removed using a small diamond round bur.• Tab. Tablet • Access cavity was made.• PRN As needed• Q6H Every 6 hours • Canals were identified (P, DB, MB I, MB II).• Male • Pulp extirpation was done using a barbed broach #15.• Female • WL was determined using the apex locator and confirmed radiographically, (P: 20 mm, DB: 19 mm, MB I: 19 mm, and MB II: 18 mm). • Instrumentation was made ē K-files #15, #20, and #25. • Intra-canal medicament (CaOH) was applied. • 2 cotton pellets were placed.Subjective • The cavity was sealed using metal reinforced glass ionomer cement. • Pt was instructed to:Objective • Improve OH. • Take Ibuprofen 400 mg tab. Q6H PRN x3 days.Assessment • N.V.: • instrumentation and obturation of the canals.Plan 14
    • Omar Hamad AlKadhi, RCsDPContents Thank You 15